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❑ New Facility ® Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Quik Stop # 124 <br /> Site Address City State ZIP <br /> 505 N . Main St . Manteca CA 953 <br /> APN Supervisor District <br /> Type of Service ❑ Application for ❑ Consultation ❑ Change of Owner Repairs or emo I Other <br /> Requested Operating Permit <br /> Commentro p/"�ed 60F12S'j2 � <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Propert Own Contractor ❑ Architect <br /> required <br /> Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property O e Contractor ❑ Architect <br /> Al <br /> First Name Last name If contractor, indicate type and license number <br /> Walton Engineering , Inc AB Haz 617238 <br /> Address City State amZIP <br /> g5691 <br /> P . O . Box 1025 West Sa ento CA <br /> Phone Phone Email <br /> 916-373- 1166 <br /> ❑ Billing Party ® Facility Owner ❑ Facility Contact ❑ roperty Owner ❑ Contractor ❑ Architect <br /> First Name Last name If contractor, indicate type and license number <br /> Quik Stop Markets , Inc. <br /> Address City State ZIP <br /> 165 Flanders Rd . Westborough MA 01581 <br /> Phone Phone Email <br /> ❑ Billing Party ❑ Facility Owner ❑ Faci ' y Contact ❑ Property Owner ❑ Contractor ❑ Architect <br /> First Name Laj6 name If contractor, Indicate type and license number <br /> oo <br /> Address City State ZIP <br /> Phone Phone Email <br /> BILLING ACKNOWLEDGEMENT: I , the un rsigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project <br /> specific ENVIRONMENTAL HEALTH DEP TMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this <br /> form. <br /> I also certify that I have prepared th' appllca, and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards, STATE and FEDERAL la s. ,, // <br /> APPLICANT's SIGNATURE : [� QiL6IL/CCL � � DATE : 07/03/2024 <br /> ❑ PROPERTY / BUSINESS 0 NER ❑ OPERATOR / MANAGER ® OTHER AUTHORIZED AGENT Contractor <br /> Title <br /> If APPLICANT is not the LING PARTY, proof of authorization to sign is required <br /> AUTHORIZATION TO LEASE INFORMATION : When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the <br /> release of any and all esults, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br /> Ac ce ted By Ass' ed To Linked FA ID <br /> c R1 V&A. O 1 <br /> Date PE 230 F ' Record Number <br /> Rev 06/12/2024 <br />